Deep Venous Thrombosis

Maria Agustina S.W. (130110100119)

Definition
Ada thrombus di deep vein Biasanya disertai inflamasi vessel wall (thrombophlebitis) The major clinical consequence is embolization, most frequently to the lung

Predisposing factors: vascular stasis, vascular damage, and hypercoagulability (Virchows triad). Thrombus is composed principally of platelets and fibrin. Karakteristik respon inflamasi di vessel wall: o Granulocyte infiltration o Loss of endothelium o Edema

Epidemiology
Deep venous thrombosis (DVT) 1000 per 100,000 persons annually in the general population > 60 years of age >50% of patients having orthopedic surgical procedures, particularly those involving the hip or knee 10%40% of patients who undergo abdominal or thoracic surgery Venous thromboembolism (VTE): DVT and pulmonary embolism VTE-related deaths in the U.S. are estimated at 300,000 annually. 7% diagnosed with VTE and treated 34% sudden fatal pulmonary embolism 59% as undetected pulmonary embolism

Symptoms & Signs

DVT of the iliac, femoral, or popliteal veins Calf pain Unilateral leg swelling Warmth Erythema Tenderness along the course of the involved veins o Palpable cord o Increased tissue turgor o Distention of superficial veins o Appearance of prominent venous collaterals o Increased resistance or pain during dorsiflexion of the foot (Homans sign) o Phlegmasia cerulea dolens (cyanotic) o Phlegmasia alba dolens (pallor) o In extreme cases, patient is unable to walk Upper-extremity DVT o Occurs less frequently o Incidence is increasing because of: Greater use of indwelling central venous catheters More frequent insertion of permanent pacemakers and internal cardiac defibrillators o Clinical features and complications are similar to those described for the leg. In both upper- and lower-extremity DVT, ~5% of patients have no symptoms.

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Risk Factors
Usually, DVT is due to multiple risk factors. Surgery: orthopedic, thoracic, abdominal, and genitourinary procedures Neoplasms: pancreas, lung, ovary, testes, urinary tract, breast, stomach Trauma: fractures of spine, pelvis, femur, or tibia Immobilization o Acute myocardial infarction o Congestive heart failure o Stroke o Postoperative convalescence o Extended time in seated position Pregnancy: ppada trimester 3 dan 1 bulan postpartum Estrogen use: kontrasepsi atau hormone replacement Hypercoagulable states Resistance to activated protein C Venulitis (e.g. TOA) Previous DVT Age > 50 years Obesity Air pollution Cigarette smoking Eating large amounts of red meat Varicose veins Oral corticosteroid use Inflammatory bowel disease

Differential Diagnosis
Disorders that cause unilateral leg pain or swelling: Muscle rupture Trauma Hemorrhage Ruptured popliteal cyst Lymphedema Postphlebitic syndrome/venous insufficiency Nerve compression Arthritis Tendonitis Fractures Arterial occlusive disorders Cellulitis

Etiology

Diagnostic Approach
Dibutuhkan assessment of pretest likelihood of DVT using Wells criteria, D-dimer testing dan ultrasonography.

Clinical assessment of pretest probability of DVT (Wells criteria) Clinical feature Active cancer Paralysis, paresis, or recent plaster Recently bedridden 3 days, major surgery requiring general anesthesia within previous 12 weeks Localized tenderness along deep venous system Entire leg swollen Calf swelling > 3 cm compared with asymptomatic side (measured 10 cm below tibial tuberosity) Pitting edema confined to symptomatic leg Collateral superficial veins (nonvaricose) Previously documented DVT Alternative diagnosis at least as likely as DVT Low clinical likelihood of DVT = 0 or less Moderate likelihood of DVT= 12 High likelihood of DVT = 3 In patients with symptoms in both legs, the more symptomatic leg is used. Score 1 1 1

International normalized ratio (INR) Monitor the prothrombin time in patients receiving warfarin Target value: 22.5

Imaging
Duplex venous ultrasonography B-mode: 2-dimensional imaging and pulse-wave Doppler interrogation o The noninvasive test used most often to diagnose DVT o Sensitivity of duplex venous ultrasonography approaches 95% for proximal DVT and 75% for symptomatic calf vein thrombosis. o Criteria for diagnosis of acute DVT: Lack of vein compressibility (the principal criterion) Vein does not wink when gently compressed in cross-section. Failure to appose the walls of the vein due to passive distension CT/ MRI Venography (venous ultrasonography) o Menggunakan medium kontras yang diinjeksikan ke superficial vein kaki.

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Treatment Approach
Anticoagulation is the primary treatment. Benefits of anticoagulation o Prevention of pulmonary embolism is the most important reason for treating DVT. o Anticoagulants prevent thrombus propagation and allow the endogenous lytic system to operate.

Clinical algorithm D-dimer adalah test pertama yang dilakukan pada pasien dengan low-tomoderate pretest probability of DVT. Ultrasonography adalah test pertama yang dilakukan pada pasien dengan high pretest probability of DVT. Hipotesis DVT bisa disingkirkan jika pasien low-to-moderate pretest probability of DVT dan negative D-dimer testing. Jika D-dimer elevasi imaging. Pasien dengan high pretest probability of DVT dan negative ultrasonogram D-dimer test. If D-dimer testing is negative, not DVT. Pasien high pretest probability of DVT, negative ultrasonogram, positive Ddimer repeat ultrasonography in 57 days.

Duration of anticoagulation

Laboratory Tests
D-dimer A degradation product of cross-linked fibrin o Levels naik pada pasien dengan thrombosis. o A sensitive (>80%), but not specific. Baseline blood urea nitrogen and creatinine measurement, complete blood count o Diperiksa sebelum treatment dengan unfractionated or low-molecularweight heparin (LMWH). Partial thromboplastin time (PTT) o Monitor anticoagulation in patients receiving unfractionated heparin Target: 1.52.5 times control value

Isolated upper extremity or calf DVT provoked by surgery, trauma, estrogen, or an indwelling central venous catheter or pacemaker: 3 months of anticoagulation Provoked proximal leg DVT or pulmonary embolism: 36 months of anticoagulation Pregnant women with acute VTE should be treated for at least 6 months, including up to 6 weeks postpartum. Patients with recurrent DVT: indefinite

Specific Treatments
Anticoagulant therapy

Initial therapy should include unfractionated heparin or LMWH. Unfractionated heparin should be administered intravenously. o Initial bolus of 80 U/kg o Followed by a continuous infusion of 18 U/kg per hour, and check PTT in 6 hours o Rate of infusion should be adjusted so that the aPTT is approximately twice the control value.

In < 5% of patients, heparin therapy may cause thrombocytopenia. Low-molecular-weight (40006000 Da) heparins

Pregnant women with acute VTE should be treated for at least 6 months, including up to 6 weeks postpartum

Inferior vena cava filter

Complications
Pulmonary embolism Post-thrombotic syndrome (also known as post-phlebitic syndrome or chronic venous insufficiency) o Chronic pain and swelling o Occurs in more than half of patients with DVT o Late adverse effect of DVT that is caused by permanent damage to the venous valves of the leg o May not become clinically manifest until several years after the initial DVT o No effective medical therapy o Most patients describe chronic ankle swelling and calf swelling and aching, especially after prolonged standing. o Most severe form: skin ulceration, especially in the medial malleolus of the leg Chronic venous insufficiency Major bleeding secondary to anticoagulation treatment Complications of heparin or LMWH therapy o Hemorrhage o Heparin-induced thrombocytopenia o Osteopenia o Thrombosis

Indications o When treatment with anticoagulants is contraindicated (e.g., active bleeding) o Patients in whom anticoagulation therapy fail Optional long-term benefit requires concomitant anticoagulation as the filter is itself thrombogenic. o Filters double the DVT rate over the ensuing 2 years after placement.

Thrombolytic drugs

Examples: urokinase, alteplase (tissue plasminogen activator) Early administration of thrombolytic drugs may: o Accelerate clot lysis o Preserve venous valves o Decrease the potential for developing postphlebitic syndrome o Increase the risk of bleeding compared with heparin Generally only used for patients with: o Limb-threatening thrombosis and o Symptoms for < 7 days and o Low risk of bleeding

Monitoring
Platelet count should be checked after 3 days of heparin therapy. Once a therapeutic INR (>2.5) has been achieved, INR should be checked: o Twice weekly for first 2 weeks o Then once weekly until stable o Then every 24 weeks Test for thrombophilic states. Duration of anticoagulation therapy o Patients with major transient risk factor: 3 months o Idiopathic DVT: 6 months o Indefinite treatment Protein C, protein S, or antithrombin deficiency Persistent antiphospholipid antibodies Homozygosity for factor V Leiden or prothrombin gene mutation Ongoing risk major risk factor (cancer) Recurrent idiopathic thromboembolism o Cancer and VTE: 36 months of LMWH as monotherapy without warfarin and to continue anticoagulation indefinitely unless the patient is rendered cancerfree

Prognosis
Prognoosis bagus untuk pasien yang menerima terapi antikoagulan. DVT kembali 5-10% selama 1 tahun berhenti terapi antikoagulan. Within 8 years, DVT recurs in ~30% of patients.

Prevention
General

Prophylaxis penting pada pasien dengan resiko tinggi DVT Treatment options include: o Low-dose unfractionated heparin (MiniUFH) 3 times daily o LMWH o Intermittent pneumatic compression devices (IPCs) o Vascular compression stockings

Prevention of postphlebitic syndrome Satu-satunya terapi untuk mencegah postphlebitic syndrome adalah dengan menggunakan below-knee 3040 mmHg vascular compression stockings.

Source: Harrisons